Farther remarks on the useless state of the lower limbs, in consequence of a curvature of the spine: being a supplement to a former treatise on that subject. 1782.

THE CLASSIC: Farther Remarks on the Useless State of the Lower Limbs, in Consequence of a Curvature of the Spine: Being a Supplement to a Former Treatise on that Subject Percivall Pott; Clinical Orthopaedics and Related Research

IT is now three years fince this ingenious and -refpe&able writer firfi: published his obferyations on the difeale which makes the fubof the prefent traft. His willies and ex-pe6bations with regard to the method of cure> Which he then propofed, have been mod pleafingly fulfilled. He has received fuch repeated teftirnony of its fuccefs from fo large a number Vol, III. N? III. Gg of of the moft eminent pra&itioners, not only in this town and kingdom, but in many other parts of Europe; that thefe, he afTiires us,, abided to his own experience, have completely fatisfied him, and enabled him to fay, that in proper cafes, and under proper treatment, he has no doubt of its being univerfal.
The difeafe in queftion, is a difeafe of the Spine, producing an alteration in its natural figure, and not unfrequently attended with a partial, or a total lofs of the power of ufing, or even of moving, the lower limbs.
From this laft circumftance (the lofs of the ufe of the limbs) it has in general been called a palfy, and treated as a paralytic afJe&ion ; to which it is in almoft every refpedt perfe&ly unlike.
The occafion of this miftake, our author obferves, is palpable ; the patient is deprived of the ufe Of his legs, and has a deformed incurvation of the fpine; the incurvation is fuppofed to be caufed by a diflocation of the vertebrse; the difplaced bones are thought to make an unnatural preflure on the fpinal marrow, and a preflure on that being very likely to produce a paralyfis of fome kind, the lofs of the ufe of the legs is in this cafe determined to be fuch: the ? ? [ "7 ] . I ^ the truth is, that there is no diflocation, no unnatural preflure made on the fpinal marrow, nor are the limbs by any means paralytic, as will appear to whoever will examine the two complaints with any degree of attention.
In the true paralyfis the mufcles of the affefted limb are foft, flabby, unrefifting, and incapable of being put into even a tonic ftate; the limb itfelf may be placed in almoft any pofition, and the joints are perfectly and eafily moveable in every direction.
In the prefent cafe, the mufcles are more extenuated, and leflened in fize, but they are rigid, and always at lead in a tonic ftate; by which the knees and ancles acquire a ftiffnefs not very eafy to overcome; by means of this ftiffnefs, mixed with a kind of fpafm, the legs of the patient are either conftantly kept ftretched out ftrait? in which cafe confiderable force is required to bend the knees, or they are by the a&ion of the ftronger mufcles drawn acrofs each other, in fuch manner as to require as much to feparate them ; when the leg is in a ftrait pofition, the extenfor mufcles ad fo powerfully as to require a confiderable degree of force to bend the joints of the knees; and when they have been bent, the legs are immediately drawn Gg 2 4 up [ "8 ] up with the heels towards the buttocks: by the j-igidity of the ancle joints, joined to the fpafmodic adtion of the gaftrocnemii mufcles, the patient's toes are pointed downward in fuch 'manner as to render it impofiible for him to put his foot flat to the ground; which makes one of the decifivechara&eriftics of the diftemper.
Thefe, according to our author, are the marks of the diftinction which ought to be made between the two difeafes. They are certainly fully fufRcient to fhevv the impropriety of confounding them with each other.
The majority of thofe who labour under this difeafe are infants or young children. Adults are by no means exempt from v ; but Mr. Pott has never feen it at an age beyond forty. "When it ^.tracks a child who is old enough to have walked properly, its aukward and imperfefl manner of ufmg its legs is the circumftance which firft excites attention, and the incapacity of ufing them at all, which very foon follows, fixes that attention and alarms the friends.
The account mod frequently given is, that for fome time previous to the incapacity, the child had been obferved to be languid, liftlefs, unwilling to move much, or brilkly, and that lie was very foon tired 5 that he ha^ been obferved They are founded upon the erroneous fuppofition of an actual dillocation, and therefore they always have been, and ever muft be, unfuccefsful. They, who have had patience and" -fortitude to bear the ufe of them to fuch a degree as to affedt the parts concerned, have always found increafe of pain and fever, and an exafperation of all their bad fymptoms, and our author has feen more than one inftance in which the atterhpt has proved fatal. He takes this opportunity to caution his readers againft the abfurd cuftom of ufing thefe inftruments to prevent growing children from becoming crooked, an an effe?t, he obfcrves, which, by forcing the fhoulders unnaturally backwards, they muft contribute to rather than prevent. If, inftead of adding to theembarrafiment of childrens drefs by fuch iron reftraints, parents would throw off all of every kind, and thereby give nature an opportunity of exerting her own powers; and if in all cafes of manifeft debility refource was had to friflion, bark, and cold bathing, with a due attention to air, diet, exercife, and the reft, the children of the opulent would, he thinks, Hand a chance of being as ftout, and as well ?hapen, as thofe of the laborious poor.
In his former publication on this fubjedt the author was led to remark, that, previous to the appearance of the curvature, the general health of the patient does not feem to be materially, if at all affe&ed. He very candidly acknowledges that a more enlarged experience in, and a more careful attention to the difeafe have convinced him that he was miftaken on this point; that moft, if not all the complaints of children, labouring under this infirmity, precede the curvature, and that a morbid ftate of the fpine, and of the parts connected with it, is the original caufe of both. An inference of the greateft importance may be deduced from this fad, as he Vol. III. N? III.
[ 2j+ 3 / is fatisfied that the malady may, in many inftances, by early and proper attention, be prevented from producing its otherwife inevitable confequences, temporary lamenefs, and permanent deformity.
In the fame edition likewife he had defcribed the bodies of the difeafed vertebrae, as being enlarged and fpread ; but upon repeated inquiry and examination, he is convinced that they are not, and that the difeafe does not fo properly enlarge as erode. The ftate alfo of the intervertebral cartilages, he finds to be fubjedt to great variety, they being fometimes totally deftroyed, while the caries is fmall in degree, fometimes apparently but little injured, where the caries has done confiderable mifchief, and fometimes totally annihilated.
The remedy for this moft dreadful diftemper conftfts merely in procuring a large difcharge of matter, from underneath the membrana adipofa on each fide of the diftempered bones forming the curvature, and in maintaining fuch difcharge until the patient fhall have recovered hishealth and limbs. The idea of this mode of treatment, it feems, was nrft fuggefted to our author by the late Dr. Cameron of Worcefter, who t 235 ] who informed him, that, having remarked in Hippocrates an account of a paralyfis of the lower limbs, cured by an abfcefs in the back, he had, in a cafe of ufelefs limbs attended with a curvature of the fpirie, endeavoured to imitate this a?t of nature by exciting a purulent discharge, and that it had proved very beneficial.
It is a matter, we are told, of very little importance towards the cure, by what means the difcharge be procured, provided it be large, that it come from a fufficient depth, and that it be continued for a fufficient length of time.
Mr. Pott has tried different means of fetons, iflues by incifion, and iflues by cauftic, and has found the lad in general preferable, being leaft painful, moft cleanly, mod eafily manageable, 2nd capable of being longed continued.
The caufticsare direfted to be applied ori each fide of the curvature, in fuch a manner as to leave the portion of fkin covering the fpinal proceffes of the protruding bones entire and unhurt, and fo large, that the fores upon the feparation of the efciiars may eafily hold each three or four peas in the cafe of the fmalleft Curvature ; but in large curves,\ at leaft as many more.

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Nothing, he obferves, can be more uncertain than the time required for the cure of this diftemper. He has feen it perfedled in two or three months, and he has known it require two or three years ?, two thirds of which time palled before there was any vifible amendment.
The firft fymptoms of amendment are ,defcribed to be a recovery of appetite, a return of refrefliing fleep, a more quiet and lefs hectical kind of pulfe, and if the patient is of an age to diftinguifh he will fay, that he has got rid of the diftreffing fenfation of tightnefs about the ftomach. In a little time more a degree of warmth, and a fenfibility is felt in the thighs, and generally much about the fame time, the power of retaining and difcharging the urine and feces begins to be in fome degree exerted.
The Hrft return of the power of motion in the limbs is rather difagreeable, the motion being generally painful and fpafmodic, efpecially in the night. At this period of the cure, we are told, it is no uncommon thing, efpecially in bad cafes, for the patient to remain fome time without making any further progrefs ; but in the milder kind of cafes, the power of voluiv tary motion generally foon follows the involuntary. The knees and ancles gradually lofe their their ftififnefs, and the patient is then able to fet his feet flat upon the ground, which is the certain mark that the power of walking Will foori follow.
The firft atteriipts to walk are feeble, irregular, and unfteady; but when patients-have arrived at this, our author has never feen an inftance in which they did not foon attain the full power of walking. At firft the patient finds it difficult to refill, or to regulate, the more powerful a<5tion of the ftronger mufcles of the thigh over the weaker, by which his legs are often involuntarily crofted. Adults find affiftance in crutches, &c. but the beft and fafeft affiftance for a child is faid to be what is called a go-cart, fo made as to reach under the arms and enclofei the whole body.
The deformity remaining after recovery is fubjeft to great variety. When one vertebra only is affe?ted, and the patient young, the curve, we are told, will, in length of time, almoft totally difappear; but where two or three are affefted, this cannot be expefted.
In his former publication our aUthor gave a fliort account of the firft two or three cafes which occurred to him. Thefe he has now omitted, becaufe the number of experiments which Thefe, different affections, we are told, are productive of many diforders, general and local, of which, ftrumous tubercles in the lungs, and a diltempered ftate of fome of the abdominal vifcera often make a part.

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When the ligaments and cartilages only, and not the vertebrae, are affe<fted, the whole fpine fometimes gives way laterally, forming fometimes one great curve to one fide, and fometimes a more irregular-figure, attended with many marks of ill health.
"When the attack is made upon the dorfal vertebras, the fternum and ribs, for want of proper fupport, neceffarily give way, and other deformity additional to the curve is thereby produced.

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The author is perfuaded that this kind of caries is always confined to the bodies of thevertebrse, feldom or never affe&ing the articular procefTes; that without this erofive deftruftion of the bodies of the vertebras, there can be no curvature of the kind which he is fpeaking of, ?r, in other words, that erofion is the fine qua non of this difeafe ; that although there can be no curve without caries, yet there is, and that> not unfrequently, caries without curve; that the caries with curvature and ufelefs limbs, is . mod frequently of the cervical and dorfal vertebras ?, the caries without curve, of the lumbal, though this is by no means conftant or neceffary ; that in the cafe of carious fpine, without curvature, it moft frequently happens that internal abfcefies are formed, and the matter either makes its way outward, or being detained within the body deftroys the patient; that what are commonly called lumbal and pfoas abfcefies are not unfrequently produced in this manner; and that a caries of the fpine is more frequently a caufe than an effedt of thefe abfcefies, Five very accurate engravings are added, reprefenting the morbid appearances of the fpine in different fubje&s.